CASE Study Skinny Reasoning PDF

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Part I: Emergency Department (ED) SKINNY Reasoning

John Taylor, 68 years old

Primary Concept Infection/Immunity

Interrelated Concepts (In order of emphasis) • Clinical judgment

NCLEX Client Need Categories Safe and Effective Care Environment • Management of Care • Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity • Basic Care and Comfort • Pharmacological and Parenteral Therapies • Reduction of Risk Potential • Physiological Adaptation

Covered in Case Study ✓ ✓ ✓

NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

Covered in Case Study ✓ ✓ ✓ ✓ ✓ ✓

✓ ✓ ✓ ✓

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Initial Triage Assessment in ED Present Problem: John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus that I hear about on the news?”

Personal/Social History: John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been married to Maxine, his wife of 45 years and is retired police officer and active in his local church. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)

RELEVANT Data from Present Problem:

Clinical Significance:

Pt complains of flu-like symptoms (headache, fever, body aches, runny nose) along with persistent cough and shortness of breath upon exertion.

Pt is a 68 y/o African-American Male with SOB & persistent cough, high risk. Flu Pneumonia Covid-19

RELEVANT Data from Social History:

Clinical Significance:

Pt lives in area with high number of Covid-19 cases, Pt is active at local church. Pt lives with his wife.

Covid-19

2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical symptoms are consistent with COVID-19?

Have you or your wife traveled anywhere recently? Have you been around anyone who was diagnosed with Covid-19? Does everyone at your church wear a mask and practice social distancing and hand hygiene? Do you and your wife wear a mask when you go anywhere out in public? Is your wife experiencing any symptoms also? Have you or your wife been tested previously for Covid-19? If so, what were those test results? Have you been vaccinated for Covid-19 yet?

3. Based on the clinical data collected, identify what measures need to be immediately implemented using the following clinical pathway. Implement Contact & Droplet Isolation ASAP Proper PPE Protocol (Mask, gloves, gown & hand sanitation) Hand hygiene, sanitize all surfaces Use disposable BP cuff Clean/sanitize all equipment Pt will be tested for Covid-19

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4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific measures must be implemented to prevent transmission?

Type of Isolation:

Implementation Components:

Contact & Droplet Isolation

Place Pt in isolation room asap. Use PPE appropriately including mask, gloves and gown. Hand hygiene, sanitize all surfaces Use disposable BP cuff Clean/sanitize all equipment Pt will be tested for Covid-19

5. What are the six steps in the chain of infection? Apply what is known about COVID-19 to each step.

Six Steps: 1.

Coronavirus COVID-19:

2.

Reservoir (location)- People,surfaces for short duration

3.

Infectious Agent (Pathogen)- Covid-19 Virus Portal of exit from reservoir- Contact & Droplet (coughing,sneezing,saliva, direct contact)

4.

Mode of Transmission- Direct contact & Droplet inhalation

5.

Portal of entry into host- Respiratory tract

6.

Susceptible host- People (Carriers included) and anyone at risk of infection

6. Is this patient a susceptible host? What step in the chain of infection does proper isolation precautions impact? Why?

Yes, he is. Precautions such as PPE and placing Pt in an isolated room ASAP are critical to preventing possible spread of infection to others. (Portal of exit and Transmission, and portal of entry to new host).

Patient Care Begins: John is brought back to a room. As the nurse responsible for his care, you collect the following clinical data: Current VS: T: 100.3 F/38.8 C (oral) P: 118 (regular) R: 20 (regular) BP: 164/88 MAP: 113 O2 sat: 92% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: “moving makes it worse” “achy” Quality: “all over” Region/Radiation: 5/10 Severity: continuous Timing:

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1. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

T 100.3 F P 118 R 20 BP 164/88 O2 sat 92% Pain 5/10

Fever Rapid pulse, needs to be closely monitored Slightly faster HBP Stage 2, needs to be closely monitored O2 sat is lower than 95, needs monitored Body aches are a S/S of Flu & Covid

2. What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX: Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: Respiratory System Cardiovascular System Nervous System CNS & PNS (central and peripheral)

PRIORITY Nursing Assessments: Auscultate (listen w/ stethoscope) to lung sounds for any wheezing or crackling sounds. (listen front, back & sides) Watch Respirations.

Monitor BP Auscultate heart sounds for any swooshing sounds/murmer Assess all pulses for rate, strength & bilaterally Assess 02 Sat and continue to monitor Continue to monitor Pt pain level

Current FOCUSED Nursing Assessment: GENERAL SURVEY: Appears anxious, body tense NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), generalized weakness HEENT: Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic nonproductive cough CARDIAC: No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Deferred GU: Deferred INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present. 3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data:

Clinical Significance:

Respiratory

Fine, dry crackles bilaterally, diminished aeration in all lobes and nonproductive cough. Weakness, though generalized and symmetrical (no signs of stroke) Skin hot (fever), no dehydration

Neurological Integumentary

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4. Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why? (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)

Problems:

Priority Problem:

Rationale: Problems: SOB/Crackling breath sounds/diminished aeration- all lobes. Body aches/pain 5/10. Fever. Priority Problem: Respiratory/breathing/crackling sounds/ diminished aeration/adequate O2. Rationale: Pt has SOB and crackling breath sounds which are serious and may indicate Pneumonia or Covid-19.

5. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)

Nursing PRIORITY:

Respiratory- pt SOB/crackling breath sounds/diminished aeration

GOAL of Care: Nursing Interventions:

To assist Pt to breath better get adequate 02.

Rationale:

Expected Outcome:

Positioning of Pt for easier breathing, explain to Pt to stay calm and take slow, deep breaths and exhale with pursed lips, apply O2 (ONLY if Physician prescribes/orders)

Pts get frightened and anxious when they cannot catch their breath. The Nurse should try to calm the patient and teach them to take slow, controlled breaths. If Physician orders/prescribes O2 or Bronchodilator meds, then apply.

Pt's breathing will become less labored and regular so that Pt will have sufficient O2.

Caring and the “Art” of Nursing 6. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? (NCLEX: Psychosocial Integrity)

What Patient is Experiencing:

How to Engage:

Pt is likely frightened and experiencing anxiety As the Nurse, I need to assist the Pt to calm down or panic. and regulate their breathing. I may lean in and place my hand on their shoulder or arm while speaking in soft, calm manner as I direct them in effective, controlled breathing.

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Reflect on Your Thinking to Develop Clinical Judgment To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? What weaknesses did this case study identify? I feel as though I understand the precautions and interventions in this case study and can apply them in a clinical setting.

I feel my weakness is that I don't always understand some of the questions entirely, I worry about answering correctly.

When I get feedback, I plan to evaluate my understanding and continue to learn the things I need to know better. ^^^

Pts in isolation are afraid and need assistance in a calm, caring manor. ^^^

What is your plan to make any weakness a strength?

How will you apply what was learned to future patients?

© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN...